Equity in educational expenditures : can government subsidies help?

When there are externalities across households, governments can improve economic outcomes by equitably subsidizing education. But this chain of causality works only if (1) allocated resources reach the final recipients, and (2) equity in public subsidies translates directly into equity in total educational expenditures, including private spending at the household level. Using a unique data set fromZambia, the author shows that whether these conditions are met depends on the specific schemes used to allocate resources as well as the exact form of the subsidies. First, subsidies allocated through clear guidelines and legislated rules reached the final recipients, but those allocated at the discretion of province and educational offices did not. Second, even those components of subsidies that were progressive (in that the share of total subsidies for the poor was greater than the share for the non-poor) had no effect on inequality in total educational expenditures due to the crowding-out of household spending.Economic Theory&Research,Environmental Economics&Policies,Teaching and Learning,Decentralization,Payment Systems&Infrastructure,Teaching and Learning,Economic Adjustment and Lending,Health Economics&Finance,Economic Theory&Research,Environmental Economics&Policies

In aid we trust : hearts and minds and the Pakistan earthquake of 2005

Winning"hearts and minds"inthe Muslim world is an explicitly acknowledged aim of U.S. foreign policy and increasingly, bilateral foreign aid is recognized as a vehicle towards this end. The authors examine the effect of aid from foreign organizations and on-the-ground presence of foreigners following the 2005 earthquake in Northern Pakistan on local attitudes. They show that four years after the earthquake, humanitarian assistance by foreigners and foreign organizations has left a lasting imprint on population attitudes. Measured in three different ways those living closer to the fault-line report more positive attitudes towards foreigners, including Europeans and Americans; trust in foreigners decreases 6 percentage points for every 10 Kilometers distance from the fault-line. In contrast, there is no association between distance to the fault-line and trust in local populations. Pre-existing differences in socioeconomic characteristics or population attitudes do not account for this finding. Instead, the relationship between trust in foreigners and proximity to the fault-line mirrors the greater provision of foreign aid and foreign presence in these villages. In villages closest to the fault-line, foreign organizations were the second largest providers of aid after the Pakistan army (despite reports to the contrary aid provision by militant organizations was extremely limited, with less than 1 percent of all respondents reporting any help from such organizations). The results provide a compelling case that trust in foreigners is malleable, responds to humanitarian actions by foreigners and is not a deep-rooted function of local preferences.Post Conflict Reconstruction,Corporate Law,Population Policies,Hazard Risk Management,Statistical&Mathematical Sciences

Which doctor? Combining vignettes and item response to measure doctor quality

The authors develop a method in which vignettes-a battery of questions for hypothetical cases-are evaluated with item response theory to create a metric for doctor quality. The method allows a simultaneous estimation of quality and validation of the test instrument that can be used for further refinements. The authors apply the method to a sample of medical practitioners in Delhi, India. The method gives plausible results, rationalizes different perceptions of quality in the public and private sectors, and pinpoints several serious problems with health care delivery in urban India. The findings confirm, for instance, that the quality of private providers located in poorer areas of the city is significantly lower than those in richer neighborhoods. Surprisingly, similar results hold for providers in the public sector, with important implications for inequities in the availability of health care.Health Monitoring&Evaluation,Disease Control&Prevention,Health Systems Development&Reform,Public Health Promotion,Educational Sciences,Health Monitoring&Evaluation,Educational Sciences,Information and Records Management,Health Systems Development&Reform,Health Economics&Finance

Money for nothing : the dire straits of medical practice in Delhi, India

The quality of medical care received by patients varies for two reasons: differences in doctors'competence or differences in doctors'incentives. Using medical vignettes, the authors evaluated competence for a sample of doctors in Delhi. One month later, they observed the same doctors in their practice. The authors find three patterns in the data. First, what doctors do is less than what they know they should do-doctors operate well inside their knowledge frontier. Second, competence and effort are complementary so that doctors who know more also do more. Third, the gap between what doctors do and what they know responds to incentives: doctors in the fee-for-service private sector are closer in practice to their knowledge frontier than those in the fixed-salary public sector. Under-qualified private sector doctors, even though they know less, provide better care on average than their better-qualified counterparts in the public sector. These results indicate that to improve medical services, at least for poor people, there should be greater emphasis on changing the incentives of public providers rather than increasing provider competence through training.

Strained mercy : The quality of medical care in Delhi

The quality of medical care is a potentially important determinant of health outcomes. Nevertheless, it remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. The authors address this gap through a survey in Delhi with two related components. They evaluate"competence"(what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality as measured by the competence necessary to recognize and handle common and dangerous conditions is quite low, albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often do not do it in practice. This appears to be true in both the public and private sectors though for very different, and systematic, reasons. In the public sector providers are more likely to commit errors of omission-they are less likely to exert effort compared with their private counterparts. In the private sector, providers are prone to errors of commission-they are more likely to behave according to the patient's expectations, resulting in the inappropriate use of medications, the overuse of antibiotics, and increased expenditures. This has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor.Public Health Promotion,Disease Control&Prevention,Health Monitoring&Evaluation,Health Systems Development&Reform,Educational Sciences,Health Monitoring&Evaluation,Health Systems Development&Reform,Educational Sciences,Health Economics&Finance,Gender and Health

India shining and Bharat drowning: comparing two Indian states to the worldwide distribution in mathematics achievement

This paper uses student answers to publicly released questions from an international testing agency together with statistical methods from Item Response Theory to place secondary students from two Indian states -Orissa and Rajasthan -on a worldwide distribution of mathematics achievement. These two states fall below 43 of the 51 countries for which data exist. The bottom 5 percent of children rank higher than the bottom 5 percent in only three countries-South Africa, Ghana and Saudi Arabia. But not all students test poorly. Inequality in the test-score distribution for both states is next only to South Africa in the worldwide ranking exercise. Consequently, and to the extent that these two states can represent India, the two statements"for every ten top performers in the United States there are four in India"and"for every ten low performers in the United States there are two hundred in India"are both consistent with the data. The combination of India's size and large variance in achievement give both the perceptions that India is shining even as Bharat, the vernacular for India, is drowning. Comparable estimates of inequalities in learning are the building blocks for substantive research on the correlates of earnings inequality in India and other low-income countries; the methods proposed here allow for independent testing exercises to build up such data by linking scores to internationally comparable tests.Secondary Education,Educational Sciences,Teaching and Learning,Primary Education,Tertiary Education

Short but not sweet - new evidence on short duration morbidities from India

India spends 6 percent of its GDP on health-three times the amount spent by Indonesia and twice that of China-and spending on non-chronic morbidities is three times that of chronic illnesses. It is normally assumed that the high spending on non-chronic illnesses reflects the prevalence of morbidities with high case-fatality or case-disability ratios. But there is little data that can be used to separate out spending by type of illness. The authors address this issue with a unique dataset where 1,621 individuals in Delhi were observed for 16 weeks through detailed weekly interviews on morbidity and health-seeking behavior. The authors'findings are surprising and contrary to the normal view of health spending. They define a new class of illnesses as"short duration morbidities"if they are classified as non-chronic in the international classification of disease and are medically expected to last less than two weeks. The authors show that short duration morbidities are important in terms of prevalence, practitioner visits, and household health expenditure: Individuals report a short duration morbidity in one out of every five weeks. Moreover, one out of every three weeks reported with a short duration morbidity results in a doctor visit, and each week sick with such a morbidity increases health expenditure by 25 percent. Further, the absolute spending on short duration morbidities is similar across poor and rich income households. The authors discuss the implications of these findings in understanding household health behavior in an urban context, with special emphasis on the role of information in health-seeking behavior.Health Systems Development&Reform,Public Health Promotion,Disease Control&Prevention,Health Monitoring&Evaluation,Health Economics&Finance,Health Monitoring&Evaluation,Health Economics&Finance,Health Systems Development&Reform,Environmental Economics&Policies,Housing&Human Habitats

Patient satisfaction, doctor effort, and interview location : evidence from Paraguay

To examine the relationship between patient satisfaction and doctor performance, the authors observed 2,271 interactions between 292 doctors and their patients in 98 clinics and hospitals in Paraguay and conducted an exit-survey with the same patients as they left the clinic. For a subsample of 64 facilities they also interviewed patients who visited the facility within the last week. There are three patterns in the data: (1) Patient satisfaction is positively correlated with doctor effort, measured as a combination of time spent, questions asked, and examinations performed after controlling for observed doctor and patient characteristics; (2) However, accounting for unobserved doctor characteristics dramatically reduces the level of significance and size of correlation between effort and satisfaction, showing that much of the positive relationship is driven by these unobserved doctor-specific factors; and (3) Reported satisfaction is significantly lower for patients interviewed at home compared with those interviewed at the clinic. This leads the authors to conclude that even if patient satisfaction reflects some aspects of the doctor's performance, unobserved heterogeneity combined with survey biases limit the widespread applicability of patient satisfaction as an indicator of doctor performance.Health Monitoring&Evaluation,Health Systems Development&Reform,Health Law,Educational Sciences,Gender and Health

The quality of medical advice in low-income countries

This paper provides an overview of recent work on quality measurement of medical care and its correlates in four low and middle-income countries-India, Indonesia, Tanzania, and Paraguay. The authors describe two methods-testing doctors and watching doctors-that are relatively easy to implement and yield important insights about the nature of medical care in these countries. The paper discusses the properties of these measures, their correlates, and how they may be used to evaluate policy changes. Finally, the authors outline an agenda for further research and measurement.Health Monitoring&Evaluation,Health Systems Development&Reform,Gender and Health,Health Economics&Finance,Disease Control&Prevention

Learning levels and gaps in Pakistan

The authors report on a survey of primary public and private schools in rural Pakistan witha focus on student achievement as measured through test scores. Absolute learning is low compared with curricular standards and international norms. Tested at the end of the third grade, a bare majority had mastered the K-I mathematics curriculum and 31 percent could correctly form a sentence with the word"school"in the vernacular (Urdu). As in high-income countries, bivariate comparisons show that higher learning is associated with household wealth and parental literacy. In sharp contrast to high-income countries, these gaps decrease dramatically in a multivariate regression once differences between children in the same school are looked at. Consequently, the largest gaps are between schools. The gap in English test scores between government and private schools, for instance, is 12 times the gap between children from rich and poor families. To contextualize these results within a broader South Asian context, the authors use data from public schools in the state of Uttar Pradesh in India. Levels of learning and the structure of the educational gaps are similar in the two samples. As in Pakistan, absolute learning is low and the largest gaps are between schools: the gap between good and bad government schools, for instance, is 5 times the gap between children with literate and illiterate mothers.Primary Education,Education For All,Tertiary Education,Secondary Education,Teaching and Learning